What is the history and purpose of the SINCERE database?

I was the director of the cardiovascular laboratory at Cedars Medical Center in Miami for about 9 years. Early in that tenure, before it became common, I had begun to perform acute myocardial infarction (MI) interventions. This was in 1994, during the days of the Johnson & Johnson Palmaz-Schatz stent. It was some of the earliest experience of stenting for acute MI. Over the next few years, I performed 137 primary stenting procedures with f
airly good outcomes. Unfortunately, I never documented those procedures as well as I should have. My practice was incredibly busy and I was the chief of a similarly busy cath lab with 36 operators.

However, when the new guidelines for door-to-balloon (DTB) time of less than 90 minutes were instituted last year, I was ready. By the third or fourth STEMI intervention under these guidelines (March 2006), I had created the SINCERE database to document these cases in an extremely diligent fashion. I also had developed a team to support me in this critical function.

I soon realized I was in an absolutely unique position. This is my twentieth year of doing angioplasty. I have a 100%-referral interventional cardiology practice. I have never needed a clinical office or had any internal medicine or clinical cardiology patients to follow on a daily basis. Being in solo practice allows me to manage my own schedule. My expertise and my immediate and complete availability have facilitated the enrollment of numerous patients in the SINCERE database.

Let me attempt to demonstrate how these unique attributes are making a difference. Three times this year, I have had 4 STEMI interventions in a single day. I was able to perform successful primary percutaneous coronary intervention (PCI) on all, and 10 of these procedures were performed with DTB times of less than 90 minutes! How would another interventional cardiologist be able to manage this? Most would have so many other commitments patients to see, elective procedures and so forth. This is where my unique situation has enabled me to accumulate such a large experience. Of course, on all these occasions, I too was exhausted and it was enormously stressful. Remember, the procedure is just one part. Some of these patients need very close follow-up post-procedure; in particular, those with cardiogenic shock. Not every patient has a perfect result and this often requires additional care. Besides, there is also the nasty paperwork and dealing with non-essential items such as medical records at 5 hospitals this itself can be a challenge.

My pattern of 24/7 availability for STEMI, short DTB time interventions has now evolved into a very unique practice. I maintain a fairly busy referral interventional cardiology practice that is often interrupted by STEMI interventions. Fortunately, my involvement in numerous new clinical protocols has not been affected. I continue to lecture and proctor PCI (both in the U.S. and internationally), and I am still managing to conduct my fairly large Annual Lumen Interventional Cardiology Symposium.

These unique advantages notwithstanding, to quickly transition into being 100% available for short DTB time STEMI interventions was still a big challenge. It has required a major personal commitment. It wasn’t until around the first 20 cases that I coined the name SINCERE. This name was chosen to highlight the fact that the data was from a single individual performing primary stenting at community hospitals. The SINCERE database has now evolved into a tremendous personal journey. Procedure number 216 was performed last night.

Was it a difficult case?

It was an extremely challenging procedure. My mean procedure time (different from DTB time) that measures the duration from needle to reperfusion has been about 16 minutes for the first 216 STEMI interventions. Yesterday, it was 46 minutes. I also missed the DTB time of 90 minutes because of numerous technical difficulties. The patient presented late in her MI one of our biggest challenges. Here we are trying to exhaust so many financial and other resources, and at best, we are looking at what you could call a relay race. We, the interventional cardiologists, are the last person handed the baton and we must cross the finish line with it.

Right now, we are focusing mainly on the DTB time, but we should also be looking at the ischemic time. This patient had been having chest pain over the last three days. She finally came into the hospital with an occluded left anterior descending (LAD) artery that had abundant, dense thrombus. Her left coronary artery (LCA) was very hard to cannulate and it was difficult to cross the thrombotic lesion with the guidewire. It was also a relatively small, tapering vessel, so I could not use the AngioJet device. Technically, it was quite difficult. I remain very annoyed at missing the 90-minute deadline. However, she had a very good outcome. I saw her this morning and she is doing well.

Is there an advantage to having a single operator in the SINCERE database?

Yes and no. I think yes, because as a single, experienced operator, I am able to do cases much faster, be more available, and use the expertise and skills that accumulate after many years in the field. The shortcomings are that ultimately you need a more pragmatic version. If SINCERE contained multiple operators, some less experienced, some in different geographical locations, maybe at different hospital groups, it would offer a more genuine representation of what one can actually expect in the community. With a single, highly experienced operator, you get a skewed representation.

Did you need to be available 24/7 for the database or was that a more personal decision?

More personal, absolutely personal. It has been about 18 months now.

How are you finding it?

Physically, very exhausting, but mentally, it is extremely rewarding. In practical terms, it has completely eliminated a predictable lifestyle. I am doing my best to handle it, but it can leave you constantly on edge. I am continually modifying my personal schedule around being completely available. Whenever I am in town, I am on call at one of five hospitals. At Memorial Regional Hospital, which is a little further from home and impossible to reach during traffic hours, I often sleep at the hospital. In 18 months, for 74 nights, I have slept in-house at that institution. After 20 years of doing angioplasty, to modify and adopt oneself to an intern lifestyle is not easy. Yet there are a few advantages too, and I am trying to look at the brighter side. Surprisingly, sometimes, I am actually able to catch up on sleep at the hospital I believe that happens as I am more relaxed knowing that I will not be driving on I-95 at 3 am! More importantly, I am able to catch up on a lot of reading too.

What this experience has done is given me a unique, hands-on knowledge as to how a successful STEMI intervention program could be developed. I have deliberately used this exercise to project a superior way of performing short DTB time STEMI interventions. As I mentioned, I live a little further away from Memorial Regional Hospital. Yet in about 75 procedures at this institution, I have had close to a 100% DTB time of less than 90 minutes. I have diligently worked to lower my own procedure times and I am constantly evolving novel ways to operate more efficiently.

If I am staying in-house, I am immediately available to evaluate the patient. I reach the cath lab ahead of the staff and before the patient has even arrived, I pull out the equipment I anticipate using. For example, for a patient presenting with an acute inferior wall MI, I pull out a 6 French diagnostic JL4 catheter. This is to take one or possibly two quick pictures of the left coronary artery to start the case. In the majority of cases, my preferred guiding catheter for interventions of the right coronary artery (RCA) is the JR4, so I’ll pull out a 6F JR4 guiding catheter. I have almost exclusively performed these procedures with a hydrophilic wire, so I’ll choose a Choice PT extra support 182 cm wire and keep it handy. In many cases, I will probably end up using a small balloon, so I’ll keep 2.5/12 size balloon catheters available. The final decision about the stent is something I leave until later in the procedure.

None of this is rocket science. In some ways, it may sound almost trivial. Yet I cannot overemphasize the urgency that exists in achieving the mandated short DTB time guidelines. Each minute is precious. Having fairly standardized equipment that I am able to predict for use in the majority of STEMI procedures saves a precious few minutes that may have been lost in equipment retrieval. My 24/7 commitment means I am immediately available. I have seen the patient and I have set the process rolling. In many cases, I try to lead from the front. As the staff is coming in, I scrub in along with them. So I am even able to help them prepare a patient. It disseminates a feeling of urgency and teamwork. It lets the message resonate that each moment is precious. My availability has been an absolutely personal decision and a calling in life, sparked by a fierce determination to get it exactly right.

When I was in high school and college, I used to run 4 by 100-meters and 4 by 400-meter relays. Initially, I was a moderate runner, but later I improved and became the final runner for the relay team. The STEMI interventions constantly remind me of times when I ran as the last relay runner. Like those relays, I am the final person with the baton and I must make up time for delays that occurred along the way. If the EMS has been slow, the clock is ticking and timed to alarm at 90 minutes. If the emergency department does not get its act together, the clock continues to tick; if transportation is slow, it is ticking still, and always, yes always, I am expected to get it right and finish within 90 minutes.

Mind you, several procedures will not be easy identification of the culprit lesion may require a thorough evaluation; vessel access can be very challenging; lesion morphology can be tricky; thrombus burden truly burdensome; hemodynamics critical and worsening by the minute; no reflow may be stubborn to usual treatment. Or, simply, a combination of these variables and darned, bad luck! Always, the interventional cardiologist is the last person who must mop up and get the timing exactly right. Now you understand why pre-selecting of the equipment can be valuable. You must remember, though, that the most critical factor for consistent outcomes is operator experience and availability. With genuine expertise, in the majority of the procedures you will have a gratifying outcome. With inexperience or delays, some brittle patients will deteriorate very quickly and may proceed to cardiogenic shock.

How important are these short DTB times? Initially, it used to be that we were watching our own numbers, but now there are all sorts of people watching these numbers. It is being required by CMS and it is being reported to Medicare and to insurance companies. As a result, what I am doing at the moment may soon become the norm in the rest of the country. For those physicians who take primary PCI call, immediate response and DTB times of less than 90 minutes will be mandated. Results for individual operators and institutions may be in the public domain. For these physicians and these institutions, some observations from the SINCERE database may be very useful.

What kind of obstacles have you faced in getting protocols in place and people appropriately trained for primary PCI at the five community hospitals?

This is a very good question. It has been extremely difficult, because there is a tremendous amount of variability. All five institutions have different protocols, different skill-sets, different response times, different levels of surgical standby and different equipment. Some even have a single type of drug-eluting stent! At one of the hospitals, the staff lives much further, so their response time is slower. They are not able to reach the hospital in 30 minutes.

At almost all the five hospitals, there is a clear dichotomy between off hours and on hours. Responses are extremely variable and I calibrate my own speed based on that.

I have tried to capture some of these variables in the SINCERE database. To illustrate this variability and to raise broader issues, I have submitted a recent abstract entitled, NASCAR Driver or Calm Thinker? Critical Ingredients for Performing Primary PCI. One of the five community hospitals where I am performing STEMI interventions has a very aggressive, EMS-initiated program. From the field, the EKG is wirelessly transmitted to the ER, Code Heart is activated by the ER physician and it is mandated that the interventional cardiologist (the NASCAR driver) and team reach the cath lab promptly. I think this is the model that the country is going to follow. However, there are challenges to this approach; mainly, more false positives. More patients who do not have a culprit lesion are taken urgently to a cath lab. In contrast, at two of the other hospitals where I perform short DTB STEMI interventions, the interventional cardiologist is the first person examining these patients (in more detail). This is the calm thinker. As a result of this more thorough evaluation of the EKG and clinical presentation, a lot more patients will not urgently go to the cath lab. However, this approach is limited in that it does institute a delay.

One particular hospital, Memorial Regional Hospital in Hollywood, Florida, has gotten it almost exactly right. They have established a world-class primary PCI program. Memorial has also been doing it longer than most. This hospital should serve as a model on how to develop a top-quality program and consistently perform 24/7, short DTB time STEMI interventions.

Very early on in creating this superb program, the team approach was emphasized. The ER and the cath lab teams met on a regular basis, every two weeks. Every acute MI was pulled out, every case which missed the DTB time was compulsively reviewed, and without trying to assign blame, there was a collaborative approach to explore ways to improve. Through this exercise, over a six-month period, we went from a 52% matching of the DTB time to almost 92-95%. Mind you, the 52% was when the DTB time was 120 minutes. Having this collaboration between the ER and the cath lab allowed us to put certain processes in place, such as monitoring the patient every five minutes throughout the patient’s course (within 0-5 minutes, the EKG is done, within 5-10 minutes it is interpreted, the cath lab is called and within 10 minutes there is access, etc.). There were numerous challenges, but collaboration and teamwork created a magnificent program.

The other hospitals where I work are fast catching up, and I do my best to help. Palmetto General Hospital is a case in point. I did the first PCI at that institution in February 2007 and already, it has become one of the top programs in town. It will probably become the busiest STEMI intervention program in Miami very soon. The staff is enthusiastic and administration is supportive. The local EMS comes to recognize a superior program pretty quickly and that is probably why the program has become so busy.

Generally, however, in contrast to Memorial Regional Hospital, I think the shortcoming at the other institutions is that the teamwork is still not as perfect as it can be. I believe the biggest challenge nationwide will be having dedicated, committed interventional cardiologists and a team approach (which also includes EMS and the emergency department).

What are your 10 Commandments for Primary PCI?

This list is the essence of what I would like to teach people. These are mere suggestions. I am too humble a person to issue commandments. These commandments will not part the Red Sea! It is simply a catchy term. Yet I hope that readers will be able to benefit from these practical tips.

The first recommendation is that for STEMI interventions with short DTB time, you have to focus and discipline yourself to stay with the culprit lesion. There must be a perfect correlation between the EKG and the angiographic culprit lesion that you are planning to intervene upon. So often, I see operators get distracted. They will treat lesions that may be critical, but are not the culprit. There may be situations where the patient is clinically or hemodynamically unstable despite culprit lesion intervention where you may want to treat another lesion, but these situations are very rare.

The second commandment involves upstream use of GP IIb/IIIa inhibitors, in particular, abciximab (ReoPro). I think it improves upon the outcome. You begin the early management of thrombus and of thrombotic lesions.

The third commandment is that a direct thrombin inhibitor such as bivalirudin has numerous advantages in performing primary stenting. Bivalirudin is the subject of the large HORIZONS trial that is nearing completion and will clarify the role of this agent in primary PCI. Almost all 216 patients in the SINCERE database were treated with bivalirudin. The results have been superior and bleeding complications have been rare.

The fourth commandment is the use of hydrophilic guidewires. Although not very popular and not without potential for perforation, I find these guidewires adept in quickly crossing thrombotic lesions. If you get proficient at handling this wire and paying attention to the distal tip, you can rapidly cross thrombotic acute MI lesions. Using a squirt of contrast, I use a rapid, rotating motion to advance the guidewire. It is also very easy to double up the guidewire after traversing the lesion. In this position, any risk to perforation is completely eliminated. I also think that the better of these guide wires is the Choice PT with Extra Support. The Whisper wire is also an outstanding wire. Amongst my recommendations, the use for hydrophilic wires may be the least emphasized. Experienced operators are able to do a superb job with various other guidewires.

The next commandment is the use of intracoronary nitroprusside. I consider this my best innovation and patients have benefited from it in numerous procedures. (The benefits of intracoronary nitroprusside are incorporated into the section below that deals with the critical parameter of the myocardial blush.)

The sixth commandment is the use of aspiration catheters. An acute MI, by its pathophysiological definition, will contain thrombus that may or may not be angiographically apparent. Given this rationale, you are better off aspirating thrombus prior to using a balloon or a stent that may cause distal embolization and/or no-reflow. My initial approach to thrombotic lesions is to cross with a guidewire and then use either mechanical thrombectomy or aspiration catheters. The Possis AngioJet device used to be the only device available, but over the last few years, several very low-profile and fairly efficient aspiration catheters have been developed. Their use takes no longer than that of a regular balloon, they offer low profiles and trackability has improved. For thrombotic STEMI lesions with TIMI zero flow, I cross the occlusion with a hydrophilic wire. If you do enough of these cases, your tactile response becomes so sensitive that you are virtually tracing the course of the artery as you advance the wire. In the vast majority of procedures, I have no doubt that the guidewire is in the true lumen. Yet if I have the slightest doubt, I will put in a small 2.0mm balloon catheter for a very quick 3-4 atm inflation to be absolutely sure that the guidewire is in the true lumen. I will then proceed with the use of an aspiration catheter. The exceptions to this strategy are large vessels with voluminous thrombus or saphenous vein grafts (SVG). In such procedures, where the thrombotic burden is larger, I believe that despite the conflicting clinical data, the AngioJet is a superb device. While the newer AngioJet catheters have much smaller profiles and the newest equipment is more user-friendly, it still takes about 8-10 minutes to set up. Often at 3 am, it will take longer. This is why the use of aspiration catheters is, I think, much better.

The seventh commandment involves the use of the clopidogrel (Plavix) test, another useful area where I think people could benefit by paying a little more attention. One of the controversies in STEMI interventions is which type of stent should be used for treating acute MI lesions. It appears prudent that almost all lesions be stented. The question is whether to choose a drug-eluting stent (DES) or a bare metal stent (BMS). The recent data from the TYPHOON and the PASSION trials does not fully provide this answer and several newer trials are exploring this critical issue. One can make a forceful argument for both strategies. TYPHOON demonstrated a benefit for DES while PASSION was equivocal. The advantage with a DES is a reduction in the revascularization rate. The disadvantage is that in an acute MI, you are placing the stent without truly establishing, in an urgent situation, the patient’s ability to take long-term anti-platelet agents. I also remain concerned that the thrombogenic milieu of an acute MI is not necessarily the best place to put in a DES. Despite this, in SINCERE, we have been able to follow 160 patients out to 30 days, and have encountered no subacute stent thrombosis.

I must hasten to add that as the database has progressed in the last 18 months, there has been a steady decrease in my use of DES. For the first 100 procedures, the use of DES was 86%. At present, for the entire cohort of 216 procedures, the rate of DES is down to 71%. The majority of BMS that I have employed are the cobalt chromium Vision platform and results appear comparable to the DES population.

The key is appropriate patient selection and a determination about the patient’s long-term ability to take anti-platelet agents. I have developed a quick 30-second Plavix test. In the huge rush to achieve short DTB times, this quick test attempts to address some critical issues. Six questions are asked: 1) Is there any coagulation disorder? 2) Is the patient anticipating any surgery? 3) Is there any pending dental work? 4) Has there been any uterine or vaginal bleeding? 5) Any problems related to the prostate? 6) Lack of insurance? Once you are doing a large volume of acute MI interventions, you will find that a large amount of patients have no insurance, which can have a tremendous impact on delivery of healthcare. Many of these patients with no insurance or any safety net may not be able to afford long-term Plavix, which may run at $4/pill. This also factors into my decisions. As I am prepping the patient, I run through the test. A firm no to all six questions and I am already down the decision path to use a DES. Lesion morphology then comes into play. I lean towards using DES for diabetics, for small vessels and for long lesions. Large vessels, including large RCA, get a Vision stent. I also know that some drug and device companies have been exploring programs where indigent patients receive free Plavix, which is a good idea.

The eighth commandment is that anything bigger than 6F is overkill. People get too concerned about having a 7F and an 8F. Every aspiration catheter, every balloon catheter and every stent is compatible with a 6F sheath an exception to this may be the 7F ThromCat from Kensey Nash. Most guiding catheters are available in 6F. So, why use a bigger sheath and have a greater potential source of bleeding? Almost all my cases are done through a 6F sheath.

The ninth commandment is probably one of the most critical elements, and in my mind, despite its arbitrary numerical assignment, it is one of the most important. It relates to the manner by which a successful acute MI intervention should be defined. There are four clinical parameters of measuring success: 1) Relief of chest pain; 2) ST segment resolution; 3) TIMI grade 3 flow; 4) Myocardial blush, grade 3. These four perimeters are something I have compulsively mandated upon myself to achieve in the last 120-130 cases. Initially, in the SINCERE experience, it was difficult enough to rush and open an occluded vessel within 90 minutes, so I do not want to understate the difficulties that are involved. Yet each of these four parameters is essential and all operators should consistently aim to meet these goals. If the chest pain has not gone, if the ST-segments have not resolved, if there is not TIMI-3 flow and the myocardial blush is poor, then you have not really achieved much.

In the last 100-odd procedures, I have strived to achieve myocardial blush grade 3, a full blush where the entire myocardium is lit up, in every procedure. It is just as critical as getting TIMI-3 flow. You can get a TIMI-3 flow by performing balloon angioplasty and by placing a stent. Despite the adequate flow, myocardial perfusion remains inadequate. Intracoronary administration of arterial vasodilators can provide significant improvements in myocardial blush by dilatation of the coronary microvasculature. Although various agents, such as adenosine, diltiazem, verapamil, nicardipine and the new The Medicines Company drug, clevidipine, may be useful, my favorite agent is nitroprusside. I universally employ intracoronary nitroprusside and remain gratified by its incredibly good results. There are numerous cases where the myocardial blush will go from grade 2 to 3 with administration of the agent.

My technique is as follows. After stent deployment, I remove the guidewire and take a picture. Then, I use intracoronary nipride (50-200 micrograms) and obtain a final angiogram in the same projection. For the RCA, the right anterior oblique (RAO) view demonstrates the blush better, and for the left coronary artery (LCA), I use the left anterior oblique (LAO) projection. With time, I will be able to objectively present more data on the specific benefits I am noticing from nitroprusside administration.

I must add that nitroprusside is not a drug you use with carelessness. It can cause severe hypotension. Quite often, this is easily manageable and if there is mild hypotension, I use a bolus of 100 micrograms of neosynephrine, which will immediately restore blood pressure. One also needs to extremely vigilant about larger doses of nitroprusside. On an average, I have found optimal results with 100-200 micrograms.

Finally, the tenth commandment is that for uncomplicated PCI, done with a DTB time of less than 90 minutes, the majority of patients can go home on the third day. Of course, discharge planning must include coronary risk factor reduction strategies and use of anti-platelets, statins, beta blockers and ACE inhibitors.

What are your thoughts on the efforts of the cardiovascular societies to decrease door-to-balloon times?

It will never be enough when you are trying to save myocardium and a patient’s life. The benefits of early restoration of left ventricular function and reducing complications of acute MI are tremendous. Any and every effort will therefore never be enough and we must continue to strive for even better outcomes.

The challenge is not only to perform short DTB time interventions; it is also to consistently do so across the country. It is to consistently deliver successful outcomes both during on hours and off hours. The challenge is also for a less experienced interventionalist who may have lower PCI volumes. There are so many cath labs clamoring to get on board with these programs, for the good reasons of saving lives and for not-so-good reasons of marketing. The challenges are for these physicians and hospitals to perform PCI by incorporating teamwork as a rigorous mandate, delivering good results in a standardized fashion, and do it every day.

Are the societies doing enough? I think we are in an early stage of a long educational campaign. One area where I think the societies need to work much harder is in getting the message out that beyond DTB time, it is also the ischemic time that is critical. Ischemic time lengthens if patient is pondering at home, if he or she is going to be delayed by the family or if there are delays in 911 to reach the appropriate facility. We also need a seamless system of triage, so that an acute MI patient is transported directly to an adequate facility providing short DTB time interventions. Primary PCI is not necessarily only a domain for the expertise of the interventional cardiologist. It is very much a public health issue and will require considerable community, local, state and federal support.

You have done a lot of work in India, Thailand, Korea, China and Singapore among other countries. Can you share some of your experiences?

My initial international relationships began after I proctored physicians for several years with excimer laser angioplasty. I used to have one of the world’s biggest experiences with the laser. It subsequently translated into proctoring atherectomy devices, stenting, rotational atherectomy and the use of bivalirudin. I am proud to have been the world’s first user of this drug for PCI. I have developed close and collegial relationships in many countries and we are collaborating on numerous clinical research protocols. I must also state with all my humility, that during most of my proctoring visits, I have learnt almost as much as I have taught, from some very talented operators.

For interventional cardiology, the differences between Asian and Western practices are getting narrower. The huge gap between us, where we had the advantage of expertise and technology, is being reduced every day. Countries such as India have become more sophisticated and several operators are highly skilled in performing complex interventions. In some specialized cardiac centers, the quality of work is comparable to what we are doing in the U.S. A lot more transseptal work is being done in India, as an example. Yet various Asian countries are still struggling with resources, with the affordability of DES and GP IIb/III agents, and some other drugs and protocols are still lacking. The area where most countries are truly lacking is in primary stenting and the short DTB times for PCI. South Korea and Japan have models which are similar to ours and they are making rapid strides. In New Delhi, along with a group of dedicated interventional cardiologists, I am setting up a program similar to SINCERE. We are calling it the Delhi Project, and we anticipate that 6-8 hospitals will perform primary PCI around the clock.

You are also the President of Indo-American Society of Interventional Cardiologists (ISIC).

Yes, this society will be better known for its commitment and its philanthropic programs. ISIC members have a large impact on interventional cardiology in the U.S. There are approximately 1,200 to 1,500 interventional cardiologists practicing in the U.S. who received their original training in India this is the definition of an ISIC member. We estimate that anywhere between 12-15% of all coronary interventions performed every day in the U.S. are done by an ISIC physician. These physicians are also very prolific contributors to interventional cardiology research and scientific publications. At the last American College of Cardiology Scientific Session, 31% of all scientific abstracts had an ISIC physician who contributed to the published work. This is quite amazing and it attests to the tremendous individual talent of Indians in interventional cardiology. ISIC was created so that we could collect this vast individual talent and provide research, training and publication opportunities for our members. We meet on a fairly regular basis and at the larger scientific meetings, we conduct dedicated ISIC educational sessions. Supporting me at ISIC is a very talented and committed executive committee that includes some of the best interventional cardiologists in the world: Dr. Samin Sharma from New York Mount Sinai Hospital; Dr. Deepak Bhatt from the Cleveland Clinic, Dr. Raj Makkar from Los Angeles Cedars Sinai Hospital; Dr. Manish Parikh at Cornell, and Dr. Chet Rihal at the Mayo Clinic. Although I am the Founder and President of ISIC, it has been the unflinching support and dedicated hard work of this executive committee that has allowed ISIC to do so well.

There are two special ISIC programs of which we are very proud. The first program is in India and is known as Stents for the Underprivileged. ISIC procures up to 200 stents each year which are donated to the poorest region of India. We have created a path for documentation to ensure that each patient receiving one of these stents is truly underprivileged, has no resources and was never charged for the stent. The second program is a bi-directional interventional cardiology fellowship. We send ISIC physicians to train in transseptal procedures at centers in India that perform several thousand mitral valvuloplasty procedures a year. To reciprocate, we sponsor exceptional fellows from India for ISIC fellowship at a top U.S. site.

Any final thoughts about your work and the SINCERE database? What are your plans for sharing in-depth data?

To your latter question first, yes, I am looking into ways to incorporate the SINCERE data with other similar projects.

Regarding this work, I would like to emphasize that this is a calling in life. It is reaching for a higher goal. It is definitely not without its sacrifice and challenge, but I do not know of anything more gratifying in interventional cardiology. I have been performing angioplasty for about 20 years and there is no greater satisfaction than primary PCI. Recently, I was able to perform a STEMI intervention procedure in 6 minutes, from needle to successful reperfusion.

The joy of being able to do this has no parallels in my professional life. Can you imagine the impact of a short DTB time intervention on a patient who often comes crashing with a massive acute MI? A few hours later, we are wondering why he is still in the hospital. STEMI interventions are one of the most miraculous medical procedures, with incredible gratification for the operator.

Personally, each procedure is a challenge, and it makes you search for excellence in every procedure. There are enormous demands on one physically. It can also be mentally draining, as there are numerous sources of stress beyond performing a skilled procedure with strong time constraints. But it is highly satisfying.

Balloon angioplasty, stenting and PCI had become routine and boring in some ways. This is a new challenge in life, something which calls for a little personal sacrifice. Anybody can do a short DTB time. Most skilled interventional cardiologists can do an exceptionally good job with short procedure times and a DTB time of less than 90 minutes when it is during regular hours. To do it regularly, day-to-day, and during off hours in a community hospital and at different hospitals, in a fairly standardized methodology, does call for a lot more dedication and commitment. Hopefully, I will have the good health and the support of the hospitals and the staff to continue doing it for many more years.

Dr. Sameer Mehta can be contacted at mehtas@bellsouth.net